Recently I had to handle a situation for a client when the workers’ compensation insurance company denied treatment for migraine headaches caused by medication given to my client by an authorized physician.
In this case, my client hurt his back badly about a year previously when he was lifting HVAC equipment. For several months, the insurance company fought us in our attempt to get proper medical treatment but eventually I was able to get him to a good doctor who scheduled him for surgery to repair a large herniated disc in his lumbar spine.
Post surgery, my client developed complications when fluid began to build up in the spinal canal. The surgeon prescribed a strong medication to help drain the fluid and prevent an infection. Unfortunately this strong medication resulted in migraine headaches.
Although the migraine headaches were new, the law in Georgia is clear that medical treatment and medications necessary to treat a complication from a compensable injury is also compensable and must be paid for by the insurance company. And, in fact, the insurance adjustor originally assigned this case, authorized my client’s pharmacy to dispense his migraine medication
Several weeks into the treatment regimen, a new adjustor was assigned to this claim. The new adjustor decided that the migraine headaches were not related to the work injury and she canceled the pharmacy authorization. Suddenly, my client was left without medication to treat his frequent and painful migraine headaches.
As you might imagine, this development left my client in a great deal of pain. I immediately got on the phone with the adjustor but she would not change her position. I then wrote the treating doctor to request a statement from him that “connected the dots” and related the migraine headaches to the original work injury. I also got on the phone to the defense attorney representing the employer/insurer to demand that my client’s prescription be approved. It took about 5 phone calls until I finally got the defense attorney to call me back – he acknowledged that our position was correct and he was able to convince the adjustor to start the medication authorization again.
This type of arbitrary action by workers’ comp insurance adjustors is all too common. Adjustors come and go and a reasonable, knowledgeable insurance claims person can be replaced by someone new who is inexperienced, stubborn or even vindictive. As a claimant’s lawyer, I make every effort to stay on top of problems like the one my client experienced and to take whatever steps are necessary to solve these problems.
Although Georgia’s workers’ compensation system is supposed to foster an environment where legitimately injured workers can get needed treatment and then return to work, the reality is much different. It has been my experience that workers’ compensation practice is just about as adversarial as divorce practice. Often justice and fair play take a back seat to “winning” and efforts by employers insurance companies to avoid paying benefits.
Case in point. This week I received the following email from a young woman who works at a factory in north Georgia:
Where I work I have been told that carpel tunnel is not recognized as a workman’s comp injury if I wasn’t having problems with numbness before. Is this correct?
The short answer is “no, this is not correct.” Repetitive motion injury (often resulting in a diagnosis of carpel tunnel syndrome) is a very common work injury, especially for factory workers performing manual labor with their hands.
Any employer who tells an employee that “carpel tunnel is not recognized as a workers’ comp. injury” is either very misinformed or downright dishonest. More on Employee Gets Bad Information About Legitimate Job Injury
As I was loading a 400lb. piece of freight on an aircraft, my (L) knee twisted. I was sent to a clinic and evaluated that I might need a knee replacement. I have a history of several knee surgeries, my job function is loading and unloading airplanes for 30 years. My question is can I obtain my own Dr. in the state of Ga., under the workmans compensation laws………Thanks
–Andrew
Jodi Ginsberg responds: Andrew, thanks for your interesting question. Here is how I would analyze your situation. First, I would want to know if your potential need for a knee replacement is the result of your most recent injury or is it a combination of this injury and your past injuries/surgeries?
Your employer and its insurer may try to argue that your current problem is the result of past injuries as opposed to this incident, and they may try to deny coverage.
Even if your employer tries to deny coverage based on your old knee problems, your case may be winnable if a treating doctor will go on record that your most recent injury aggrevated your pre-existing condition, and if you did not misrepresent your knee problems at the time you were hired.
If your employer has accepted responsibility for covering your knee problem, then the next step would be to get you to a specialist. Under Georgia’s workers’ compensation law, an authorized treating doctor can refer you to a specialist and, generally, the insurer would be responsible for paying the specialist to treat you. If your employer has a valid "posted panel of physicians" there may be a specialist there that you could choose.
If the employer is denying coverage, you would need to request a hearing on the issue of whether your injury is compensable.
As you can see, the answer to your question depends on a number of factors. I do not think you can or should assume that your employer or its workers’ compensation carrier will act in your best interest.
Feel free to call me at 770-351-0801 if you wish to discuss further.
[tags] knee injury and georgia workers compensation, arising out of and in the course of employment, pre-existing condition and workers compensation [/tags]
I wanted to know if there was anything that could be done to help me. I had surgery on my left shoulder and have reached MMI with a disability rating and significant work/lifting restrictions (I’m a nurse). Now, my right arm is starting to grind and bother me. I know it’s from overuse of it because I had no problems with it until I kept having surgeries on my left (3) and had to use it all the time. Is this a part of my workers comp. claim or do I have to be on my own with this?
Sonji
Jodi Ginsberg replies: Sonji, he injury to your right arm is potentially compensible as part of your workers’ compensation claim. If your authorized treating physician will agree that the problems you are having with your right arm are consistent with overuse that is reasonably and logically the result of having only one functioning arm then you have a strong argument for benefits.
[tags] arising out of the course of employment, georgia workers compensation, overuse syndrome [/tags]
North Carolina workers’ compensation lawyer Dan Deuterman recently wrote about one of his cases, Clark vs. WalMart, that ended up in the North Carolina Supreme Court. Although the Clark case arose under North Carolina law, there are implications for Georgia workers’ compensation claimants.
Mrs. Clark, a 64 year old lady, worked as a greeter at WalMart. She injured herself while attempting to move a decorative sled while standing on a 10 foot ladder. Ms. Clark had previously been diagnosed with osteoporosis. After initially accepting the claim, WalMart cut Ms. Clark off, arguing that Ms. Clark was not entitled to presume that her on-going back pain was solely the result of her job injury given the pre-existing osteoporosis.
The North Carolina Supreme Court agreed with WalMart that Ms. Clark, as the injured employee, had the burden of proving that her on-going disability arose from her job injury and remanded the case back to the North Carolina Industrial Commission (which is roughly equivalent to the Georgia State Board of Workers’ Compensation). The Industrial Commission ruled that Ms. Clark was permanently disabled and that WalMart had to pay for her medical care, including spine care associated with osteoporosis.
This case highlights an issue that we often see here in Georgia. Often our client’s work injury is not the only medical problem afflicting him or her. Sometimes, our client has a pre-existing medical problem (one known to the employer) that makes recovery from the new on-the-job injury more time-consuming or complicated. Sometimes an unknown medical problem will arise due to the stress and shock of a sudden work injury.
Employers and their insurers will attempt to limit the medical treatment to the specific work injury and will refuse to pay for medical treatment that is not directly related. As you might imagine this stance creates issues as often the “other” medical problem limits healing or affects treatment. Certainly, in Mrs. Clark’s case, her job injury at WalMart did not cause her osteoporosis, but the osteoporosis most definitely affected her healing and the extent of her recovery.
As is the case in North Carolina, disputes between employers and their insurers about what constitutes compensable care ends up before workers’ compensation judges.
[tags] Clark v. Walmart, pre-existing conditions, payment of medical care in workers’ compensation cases [/tags]
I would like some info. I was injured on the job last week. Actually I broke my foot while working in the woods. My employer said to present him a bill and he will pay instead of filing workers comp. Who is that benefiting he or I? I have since worked everyday just limping along. It hurts alot, but I have a family and cannot miss a paycheck. If he doesnt pay the bills what should I do, or should I do something now? Please advice.
–Edgar
Jodi Ginsberg responds: Edgar, the purpose of workers compensation is to allow an injured worker to get the proper care and income benefits when he cannot work at all or at his normal job. However, workers’ comp is not a choice that your employer gets to make – if you are injured on the job, you have the absolute right to file a claim. Your employer is trying to get you to avoid the system so he does not have to put a claim in to his wc carrier.
In my opinion, that approach is not good for you. You need proper medical care; weekly benefits and the time to heal from the injury. You should not play games with your health.
In addition, if you try to submit medical bills from an on-the-job injury to your health insurance company, they will probably reject the claim as workers’ compensation is considered the primary insurer in an on-the-job injury claim.
Finally, in a worst case scenario, if you do not file your claim and a year goes by, you may lose the right to file for workers’ comp. because of the statute of limitations. If your employer should then decide to stop paying for your medical care, you could be out of luck.
I realize that sometimes injured workers do not like to “rock the boat” and therefore may not to press the issue with their employers. Unfortunately, however, it has been my experience that employees who try to “help” their employer usually end up with the raw end of the deal. At the very least, therefore, please call me at 770-351-0801 so we can discuss what is in your best interest.
[tags] workers comp vs. health insurance, not filing on-the-job injury claim under workers compensation, workers compensation and statute of limitation [/tags]
As a rule, if you are injured traveling to or from work, you are not covered by Georgia workers’ compensation. However, there is an exception to this rule. These exceptions include:
- instances when your employer provides transportation
- when you do doing some function that is permitted or required by your employer
- when you are walking to or from the parking lot provided by the employer
- when you are an “on-call” employee and your employer furnishes transportation
- when your employer provides you with a vehicle, you are covered when you enter the vehicle and stops when finish your job task
As you might imagine, there is a lot of litigation when an employee is injured off the worksite. There are literally hundreds of published cases and our experience has been that every case has to be analyzed on its own merits. Therefore, if you are injured off site, you may have an uphill battle, but do not assume that there is no way that you are covered.
Fact specific situations are ones where experienced legal counsel can be of great help to you.
[tags] workers comp coverage when traveling to or from work, ingress, egress, georgia workers’ compensation [/tags]
